Healthcare Provider Details

I. General information

NPI: 1114662913
Provider Name (Legal Business Name): BONNIE QUACH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2022
Last Update Date: 07/05/2022
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 CONCORD AVE STE B
CAMBRIDGE MA
02138-1380
US

IV. Provider business mailing address

33 GILBERT ST
WATERTOWN MA
02472-1783
US

V. Phone/Fax

Practice location:
  • Phone: 617-945-2906
  • Fax:
Mailing address:
  • Phone: 857-204-9525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5532
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: